Asian Rhinoplasty Tutorial
The Asian nose is very different from the Caucasian nose in many respects. First, the overlying skin is typically quite a bit thicker than that of the Occidental individual. Secondly, the underlying cartilage tends to be thinner and less firm. These two attributes are the two most important anatomic features that impact the technique that should be selected for Asian rhinoplasty. These attributes can also be found in some Caucasians, African-Americans, Hispanics, andin Middle Eastern races but to a lesser extent. Skin and cartilage thickness and rigidity directly affect the method for refinement of the nasal tip. In individuals with relatively thinner skin and thicker cartilages, the cartilages can be refined and the thinner overlying skin will show the improvement as it redrapes over the new framework. However, this is not the case with the typical Asian nose.
As the following illustration demonstrates, narrowing the cartilages under thick skin will lead to a worsening of the condition rather than an improvement. After the cartilage is refined and narrowed through traditional Western techniques, the thicker skin will not redrape over the narrowed framework. Accordingly, there is a dead space that develops between the narrowed cartilage and the unyielding thicker skin. Over time, scar tissue develops in this dead space leading to a rounder, more bulbous tip. The end result is that the tip will look actually bigger and less refined. Instead a cartilage tip graft is used (taken typically from the septum inside the nose) to project the nose forward and thereby create a narrower appearance by pushing the thicker skin forward. This technique is actually unacceptable in the thinner-skinned patient, where the graft can become visible over time. Therefore, a careful physical examination (see the Rhinoplasty Tutorial for more information) is mandatory to determine which method or methods would be appropriate in your case.
In the following diagram, Dr. Lam demonstrates various types of cartilage tip grafts that increase tip structure, support, and appearance. He does not always use all of these grafts but will do so depending on your individual anatomic requirements.
In some instances based on cartilage and skin thickness, Dr. Lam may find that narrowing of the cartilages will provide the best results at a more refined nasal tip. In the following case, the patient demonstrated medium thick skin but thicker cartilages and Dr. Lam undertook narrowing of the cartilage framework to achieve the desired narrowing of the nasal tip. A Gore-Tex implant was used to raise the bridge at the same time to create a balanced result. The patient previously had a silicone implant performed in Taiwan that had slid down to the bottom of the nose, which Dr. Lam had to remove first.
Another concern that is oftentimes expressed by the Asian or ethnic patient is the desire to narrow the base of the nose. A flared nostril may contribute to an overly ethnic look and also create an unbalanced appearance. Dr. Lam does not always narrow the base of the nose for two reasons. First, it is oftentimes unnecessary and can also lead to a more unbalanced result in some cases. For example, if the tip of the nose is very wide, narrowing the sides of the nose can actually make the tip appear even wider. If you have a wider tip and you squeeze the sides of your nose, you will see that your tip will suddenly appear wider and bigger. Understanding harmony and balance is important to attain the correct results.
In narrowing the nasal base for those individuals that should require it, Dr. Lam uses a combination of techniques. In order to decrease the nostril width, he makes an isolated incision that remains for the most part inside the nose, known as a nasal sill reduction. This unique strategy ensures three benefits. First, the incision is kept in a place that tends not to prolong recovery time, like the incision that circumscribes the outer part of the nose. This technique truly reduces the size of the nostril in those individuals that need it. Finally, reducing the nostril in this way helps prevent over reduction of the outer part of the nostril that can lead to a loss in natural curvature and shape of the nostril itself.
If your nostril is not too wide but too flared (too round), then a Sheen flap reduction can be beneficial to achieve less of a flared nostril. The Sheen flap preserves a very small island of skin so that the natural curvature of the nostril is not violated. If you look at Michael and Janet Jackson’s noses you will see two major problems: a loss in natural curvature of the sides of the nose as well as a notched appearance at the base of the nose. By using the nostril sill reduction to reduce the width of the nose and the Sheen flap to reduce the flare of the nose, Dr. Lam can truly tailor a very customized solution in every case.
A wide reduction of the nostril base that extends all the way into the nostril is a bad technique that can lead to the aforementioned flattening of the natural nostril curvature and a notched appearance that is unnatural as well.
If you look at Janet Jackson’s nose, you can see the flattening of the outer nostril as well as the notched appearance along the nasal sill that is very unnatural looking.
A major concern of most Asian patients seeking rhinoplasty is whether the bridge of the nose will be made too high or if it will look like a Popsicle stick shoved inside the nose. The older solid silicone implants that Dr. Lam used to use unfortunately led to these types of problems. Here are the reasons why Dr. Lam no longer uses silicone as his implant of choice for Asian rhinoplasty. First, solid silicone tends to cause a shrink-wrapping of the skin around the implant, which leads to a visibility of the implant edges and thereby an unnatural result. Second, silicone is very hard (even the softer versions) and can feel unnatural. Third, silicone is very heavy and in some patients can tend to shift and slide downward to cause problems with the nasal-tip skin. For all of these reasons, Dr. Lam prefers now to avoid using solid silicone in building Asian noses.
This woman had a silicone implant placed in Vietnam and is shown with the implant having slid downward to cause a hole at the tip of the nose. Dr. Lam rebuilt the nose using a cartilage graft for the tip of the nose, Gore-Tex for the bridge of the nose, and performed a scar revision to improve the appearance of the bottom of her nose.
The concern of raising a nasal bridge too high is legitimate considering the number of individuals who exhibit a very fake looking bridge. Dr. Lam does not use Western standards of beauty for raising the nasal bridge but tries to adjust the nasal bridge height to match your gender, ethnicity, and facial features. In general, the top of the Asian nose should end approximately at the middle of the eye level, whereas in the Western nose the bridge should ideally terminate at the top of the eyelid crease. The elevation of the nasal bridge to this level can look unnatural in many Asians and should be avoided in many cases.
The following patient demonstrates improvement in her nasal appearance by raising her nasal bridge to an appropriate height. As part of an understanding of harmony, notice that the nasal tip appears smaller after raising the nasal bridge even without modification of the nasal tip itself.
For minor modification of the nasal bridge height after rhinoplasty, Dr. Lam can further raise the bridge height as desired using micro droplets of liquid silicone. Although Dr. Lam does not like using solid silicone implants, he occasionally uses micro droplets of liquid silicone as needed to enhance the nose further when warranted. Dr. Lam is very hands on with his patients after rhinoplasty to ensure that the result is as perfect as he can deliver every time.